Preventative interventions by dental care professionals in Africa on oral human papillomavirus, gonorrheal, chlamydial, syphilitic and trichomonas infections: A scoping review

Abstract Background Oral human papillomavirus (HPV), gonorrheal, chlamydial, syphilitic and trichomonas infections are very common sexually transmitted diseases (STDs) in Africa. However, no known study has reviewed the available evidence concerning the preventative interventions by dental care professionals (DCPs) in Africa on oral STDs; hence, this scoping review was conducted to evaluate the research landscape of this topic area in Africa. Methods The scoping review methodology and documentation were informed by the Arksey and O'Malley's guideline, the Preferred Reporting Items for Systematic Reviews and Meta‐analysis extension for conducting Scoping Reviews (PRISMA‐ScR) checklist, and the AMSTAR‐2 guideline. Ten electronic research databases were searched to retrieve literatures relevant to the scoping review question. The retrieved literature were deduplicated and screened for eligibility based on the review's selection criteria. Data charting, collation and summarization were intended to be done in this review, but it could not be done because no relevant literature was found eligible for inclusion into this scoping review. Results A total of 523 literature were retrieved. After deduplication of the retrieved literatures, the residual literatures (n = 353) were screened for eligibility for inclusion into the review, of which no eligible article was found. Hence, this scoping review was an empty review. Conclusion This empty scoping review demonstrates that DCPs in Africa do not engage in research‐based oral STD prevention. Therefore, the implementation of research‐based preventative interventions, by DCPs, on oral STDs should be encouraged in Africa.


| INTRODUCTION
Sexually transmitted diseases (STDs), previously referred to as sexually transmitted infections (STIs), are conditions caused by the transmission of a broad array of pathogens between sexual partners through diverse routes of sexual contact, such as anal, vaginal, or oral route. 1 Sexually transmitted diseases has remained as an issue of global public health concern due to its close association with natural physiologic response which is "sex" and majority of persons affected with these diseases goes untreated with serious consequences. 2 While these diseases are most prevalent in adolescents and young adults (due to high sexual activities), the most serious consequences occur later in life. 1 The eight most common STDs include four incurable but treatable infections (human papillomavirus [HPV] infection, human immunodeficiency virus [HIV] infection, herpes simplex virus [HSV] infection, and hepatitis B) and four curable infections (trichomonasis, chlamydiasis, gonorrhea, and syphilis). 3 Global epidemiological data for STDs states that the incidence of STDs is very high in several countries, especially among individuals between the age of 15 to 50 years. 3 Additionally, more than one million new cases of potentially curable STIs, mostly asymptomatic, are acquired on daily basis. It is further reported that 376 million new infections occur every year, involving at least one of the four curable STIs (gonorrhea, syphilis, chlamydiasis, and trichomoniasis). Of these, the burden of trichomonasis is the highest, with over 150 million new cases annually, closely followed by chlamydia, gonorrhea, and syphilis at 127 million, 87 million, and 6.3 million, respectively. 3 Human papillomavirus (HPV) is the world's most prevalent sexually transmitted viral disease. 4 In the United States of America alone, the burden of HPV infection is 80-110 million total cases with 14-20 million cases reported each year. 5,6 Oral sex is a form of sexual activity which involves the use of the mouth, teeth, lips, tongue or throat to stimulate the genitalia. 7 It is a common practice among sexually active adults of all ages, socioeconomic status, sexual orientations, and races. [8][9][10][11][12] This route of sexual contact can pose similar risks as other sexual routes such as vagina and anal sex. 1 People may engage in oral sex (anlingus, fellatio, or cunninlingus) as part of foreplay before sexual intercourse, or during/after penetrative vaginal/anal intercourse. 7 Therefore, oral sex is a potent route of transmission of syphilis, 13 gonorrhea, 14,15 HSV, 16 HIV, 17 chlamydia, 18 and HPV 15 infections. Sexually transmitted oral infections, caused by carcinogenic pathogens, particularly HPV, is an emerging public health problem negatively impacting the field of oral health due to its ability to cause oropharyngeal cancer. 19 Consequently, dental care professionals (DCPs), including dental surgeons, dental therapists, and dental hygienists, must play an important role in the prevention of oral STDs (i.e., oral infections contracted through oral sex) in dental patients.
With the persistently high burden of STDs, particularly those transmitted orally, in Africa, it is very crucial to evaluate the existing preventative interventions used by DCPs in preventing the problem, as this information will provide deep insights on the current landscape concerning this public health issue in Africa. 3 However, the volume of studies, as well as the depth and breadth of the available evidence, on preventative interventions by DCPs in Africa on oral HPV, gonorrheal, chlamydial, syphilitic, and trichomonas infections is currently unknown; hence, the justification for this scoping review. This study therefore aimed at reviewing the existing literature on the preventative interventions of DCPs in Africa on oral HPV, gonorrheal, chlamydial, syphilitic, and trichomonas infections to identify the landscape of this area of research interest.

| Design
This scoping review adopted the research design proposed by Arksey and O'Malley 20 and the AMSTAR 2 guideline informed the methodological and reporting process, to ensure quality. 21 Also, the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for conducting Scoping Reviews (PRISMA-ScR) checklist guided the presentation of this review. 22

| Review question
Like other scoping reviews, 23 25 Based on this framework, 25 the population of interest was dental patients; the concept was health interventions, by DCPs (dentists, dental specialists, dental hygienists, dental therapists, etc), on oral HPV, gonorrheal, chlamydial, syphilitic and trichomonas infections; and the context was Africa which comprised of 54 countries, 2 dependencies and 2 territories. 23 Appendix: Tables A1-A3 show the search strings obtained from the scoping search of these 10 databases.

| Selection of literature
The literature retrieved from the database search was downloaded from these databases and imported to Rayyan software for deduplication. 26 All duplicate records were expunged, and the residual literature was screened for inclusion in the scoping review based on a set of criteria highlighted below:

Inclusion criteria
• Literature published in peer-reviewed journals.
• Literature published in English.
• Literature reporting empirical findings.
• Literature adopting any research design.
• Literature on studies conducted among dental patients in Africa.
• Literature with accessible full text.

Exclusion criteria
• Literature that was not published in peer-reviewed journals (e.g., books, book chapters, etc).
• Literature not published in English.
• Literature that did not report empirical findings.
• Literature on studies conducted among dental patients outside Africa.
• Literature on studies conducted among nondental patients in Africa.
• Literature with inaccessible full text. A literature is considered to have inaccessible full text if the authors could not retrieve such full text from the British Inter-Library Loan or the corresponding author of such literature.
The screening process was in two stages. The first stage involved title and abstract screening to exclude obviously nonrelevant literature. Only the literature excluded in the first stage was screened at the second stage. In the second stage, screening of full text was done. Only the literature that met the above-highlighted inclusion criteria were considered eligible for inclusion into the scoping review.

| Data charting, collation, and summarization
In scoping reviews, data is extracted, collated, and summarized from the included literatures, provided they available. 23,24 However, this was not accomplished in this scoping review because no literature was found eligible for inclusion into the review. Hence, this is an empty scoping review.  Table 1 shows the list of the literature whose full texts were screened in this review. The paper by Martini et al. 27 was a case report on a DCP-led intervention in Italy (Europe) on a Nigerian sex worker with oral HPV infection. The paper by Muzyka et al. 28 was a prospective cohort study on pregnant females living with HIV in rural Malawi; however, the study did not involve a DCP-led intervention.

| RESULTS
The paper by Masiiwa and Naidoo 29 was a before and after study on DCP-led intervention on HIV-infected patients; however, the study population characteristics did not indicate that the studied population were patients who contracted oral diseases/infections through oral sex. Based on the review's selection criteria, none of these papers was included into this scoping review. Oral sex is commonly practised among heterosexuals and homosexuals in Africa, 30,31 but published interventions on the prevention and care of oral STDs, particularly in the dental care settings, are not available. This shows that oral STDs in Africa is a neglected public health area in Africa.

| DISCUSSION
Pertinently, oral sex is commonly assumed to be a safer sexual practice when compared to genital-genital sexual practices. 7 However, as it is with other sexual practices, the exchange of body fluids often increases the risk of contracting oral STDs, especially when there is any form of cut or wound in the mouth, or genitalia. 7,32 It is also notable that the incidence of oral STDs is on the increase globally while the use of preventive measures against the disease is relatively low. 33 In a recent survey of a sample of dental surgeons in Nigeria, Africa, it was observed that majority of them were unaware of the protective measures that can be used to prevent the transmission of oral STDs during oral sex 30 ; hence, this may be a major factor contributing to the lack of preventative intervention, by DCPs, on oral STDs in Africa. Also, in the survey, 30 it was identified that the practice of educating dental patients on the risks of unprotected oral sex as well as the precautionary measures that can be adopted to KANMODI ET AL.  34 Unfortunately, the prevalence rates of unprotected oral sex in several African countries are high 31 ; however, this finding is similar to that observed elsewhere. 35 For example, in a study, by Strome et al. 35 it was reported that less than 10% of a sampled youth population in the USA ever practised protected oral sex. Overall, this shows that unprotected oral sex is a common practice in several countries of the world; hence, the practice is a global sexual health problem.
However, Africa has one of the greatest share of the STD disease burden. 30,31

| CLINICAL RELEVANCE
The findings obtained from this empty scoping review indicates that there has not been adequate research engagement of DCPs in Africa in the prevention of oral STDs. However, it is also possible that such engagements might exist in Africa, but they have not been captured with adequate research. Hence, this is a research gap that needs to be filled, as evidence on this public health area is very crucial for the development, implementation, and evaluation of public health policies on sexual health promotion and oral STD prevention in Africa.

DATA AVAILABILITY STATEMENT
Data sharing is not applicable to this article as no new data were created or analyzed in this study.

TRANSPARENCY STATEMENT
The lead author Kehinde Kazeem Kanmodi affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.  S5 S1 AND S2 AND S3 AND S4 S1 AND S2 AND S3 AND S4